Crazy Medication Administration Errors – Adventures in Patient Education

Teaching patients how to use their medications is at the heart of what we do as pharmacists.  I wanted to share some of the crazy medication administration errors that I have seen or heard of.  I also encourage you to comment below if you have some good ones that you can contribute.  While we might chuckle at these, many of these errors have or can lead to poor outcomes and harm to our patient.

  1. I think if you have worked as a pharmacist for a while, you have likely encountered a patient who has had misadventures with suppositories.  One example that I’ve encountered is a patient trying to take them orally.
  2. Using is insulin can greatly improve A1C’s, but not if the patient is not getting the dose.  I heard of a scenario where a patient went years with severely high A1C’s.  He had thought that when he put the needle on his pen, he didn’t need to take off the cover.  He had thought this because of his lancet device.  With the lancet device, the needle is hidden from view and comes out through the device when the button is pushed.  He thought that the insulin needle was the same way.
  3. Then there was the gentleman with Spiriva for COPD who was swallowing the capsules instead of putting them in the device for inhalation.
  4. I’ve also heard of patients who have drank the nebulizer liquid instead of using their nebulizer machine.

These are just a few examples of medication administration errors I’ve seen in practice.  I know there are numerous other examples, and in an effort to educate other pharmacists and healthcare professionals, I would love for you to leave your example(s) in the comments below.


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1 Comment

  1. Margaret Ann Henderson

    Strangest administration event I had was a young man who called in a panic because he had been out cutting grass and came in and drank his girlfriend’s bottle of water. Turns out, she was dissolving her thyroid pills in the water (a weeks worth or more at a time) and then would take a sip of the water every day. I wasn’t so worried about the guy, as the thyroid would adjust automatically to the exogenous dose -but I was seriously worried about his girlfriend!


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Written By Eric Christianson

April 22, 2018

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